PMBOK (Marco de Referencia para la Gestión de Proyectos)

This set of analyses sought to qualitatively examine how social conditions shape sexual norms and risk behaviors of structurally vulnerable, African American, male substance-users who report high-risk sexual behaviors with men and women. Two specific sexual risk behaviors were then studied. The association between personal network composition and social support function on the sale of sex for drugs or money was tested among a similar set of men. Then the association between sexual partner dyad characteristics and social support function on unprotected sex was tested.

The findings from this study, and the process of mixing methods at several stages of research, contribute to the expanding use of mixed methods in public health research. The study elucidates how a greater understanding of the social conditions experienced by the men who participated in the in-depth interviews supports the hypothesized relationships that examined the predictors of sexual exchange and condom use among a similar set of men who completed the network-based surveys. The first study aim advances the knowledge base on how social conditions shape sexual norms and risk behavior among men about whom little is known and who have received little systematic public health attention. It addresses gaps in the literature which may inform sexual risk reduction interventions that are socially and culturally relevant to men similar to those who participated in both parent studies. The results may also provide insights that guide the development of policies that are context sensitive. The second and third study aims contribute to the growing body of evidence that demonstrates how social networks assert their influence on

health behavior which may inform peer- and network-based interventions tailored for African American male substance-users. Such implications are explored in depth later in this chapter. The chapter continues with a brief discussion of the significance and process of mixing methods for this study. I then provide an interpretation of the emergent themes from the first study aim as they relate to a framework called the Continuum of Violence. This section is followed by an integrated summary of the findings for all three study aims with the intention of producing a comprehensive “end product that is more than the sum of the individual quantitative and

qualitative parts” (148). Illustrative quotes from the first study aim provide further insights into the explanation of the quantitative findings. The integration of the qualitative and quantitative findings takes on a more summative, rather interpretive form. I refer to the men who participated in the network-based survey study as ‘respondents’ and the men who participated in the in-depth interviews as ‘participants.’ I end this chapter by addressing the methodological limitations, and discussing the implications for further research, practice and policy.

Mixing qualitative and network-based data was appropriate for answering the guiding research questions for Aim 1 and testing hypotheses for Aim 2 and Aim 3 because network-based inquiry maps social processes that drive individual behavior, and qualitative inquiry is equipped to answer the ‘how’ and ‘why’ of social processes. This mixed methods study answered a complex set of research questions by mixing methods at three of the four stages of research. Though the present study was a secondary analysis, the guiding questions for the first study aim and research questions and hypotheses for Aim 2 and Aim 3 were complementary and of my own

conceptualization. At the data analysis stage, I integrated the study by conducting concurrent analyses. For example, the quantitative data analyses for Aim 2 and Aim 3 were considered

throughout the qualitative code development and memo writing completed for the first study aim. Though I wrote two separate manuscripts for this dissertation, including one for qualitative first

study aim, and another for the second and third quantitative study aims, I also interpret the findings from all three study aims in an integrated manner later in this chapter.

7.1.1 Interpretation of Emergent Themes from Aim 1

The structurally vulnerable, African American, MSMW who participated in the qualitative parent study reside in social environments that are not supportive of HIV/STI prevention behaviors. Among the men in the study who were attracted to other men, there appeared to be little space for them to be themselves. Among the men who did not appear to be sexually attracted toward other men, yet engaged in sexual exchange for drugs or money, there appeared to be limited

opportunities to meet their basic needs that did not necessitate the commodification of their bodies. Furthermore, a greater understanding of the social conditions that shape the incongruences between sexual identity, attraction and behavior were made clearer by the men’s narratives. However, rather than focusing on reconciling sexual incongruences, there is a more urgent need to understand and address the persistent influence of violence on masculine identity that appears to be negatively impacting these men’s sexual health.

With regard to the social conditions that shape the intersecting sexual and substance-using norms and behaviors that place structurally vulnerable men at risk for HIV and other STI, the qualitative study found that their exposure to violence, ranging from personal addiction, assault, and incarceration to institutional racism and homophobia, shaped their sexual behaviors. The narratives of historical and present-day violence described by the men suggest that these

experiences take on dynamic and dramatic meaning in their lives and that sexual risk behavior is a reasonable response to such micro and macro forces over time. The political, structural, symbolic

engage in sexual risk behavior to negotiate social status and power despite the cost of undermining their health. These findings are consistent with Whitehead’s description of men’s cultivation of respect and reputation through sexual prowess when economic capacity and sociopolitical power are scarce. As social actors, the men’s sexual risk behavior is reflective of the social marginalization that defines their lives and what Whitehead refers to as “fragmented masculinity” (152).

The men’s sexual risk behaviors with other men were nearly always discussed in a manner to suggest that these behaviors are necessary coping strategies exercised by men living on the margins of society. Consistent with Harawa and colleagues’ work establishing the role of substance use as motivation and justification for sexual behavior with men (63), the use of substances by the men in this qualitative parent study was described as an outgrowth of, and often a necessary part of, their sexual experiences and partnerships with men. However, these maladaptive coping strategies do not support the formulation of risk reduction strategies, including condom use, serosorting and strategic positioning that could ease the disproportionate HIV and other STI burden faced by high-risk, African American, substance-using MSMW.

7.1.2 Integrated Summary of Findings for Aims 1, 2 and 3

The mixed methods study broadens our knowledge about sexual exchange and personal network composition and social support function. The study also provides greater insight into selective condom use within sexual partner dyads. Although, such clarity arrives principally from the third study aim, as narratives about condom use were surprisingly scarce in the qualitative data. The study moved beyond the limitations of individual behavioral research and contributes to our

understanding of sexual norms and risk behaviors in relationship to social arrangements and functions.

As hypothesized, the quantitative study Aim 2 respondents’ likelihood of selling sex for drugs or money was significantly higher if they had a greater proportion of peers with a history of incarceration, although this relationship was no longer significant in the multivariate model. The significance of peer incarceration on the respondents’ sale of sex for drugs or money contributes to a related body of work documenting the correlation between individual and sexual partner history of incarceration and HIV-related behavior and infection (20, 67, 82, 89, 198, 199). The proportion of employed peers was protective toward the sale of sex for drugs or money, which confirmed my hypothesis. The influence of peer employment aligns with strong evidence suggesting that unemployment, low income status, history of incarceration and other forms of structural

vulnerability are significant predictors of sexual risk behavior, including sexual exchange (10, 20, 21, 131, 133). The vast majority of the participants from qualitative parent study described their sexual risk behavior with men as a means of meeting their substance use needs. A subset of the men also described having sex with men for money to purchase clothing and shoes in order to participate in an image-based consumer society while they struggled to secure steady employment and housing. Gregory, for example, is a 37-year-old, bisexual-identified man who is unemployed, has an

undisclosed HIV status, a high school education and a history of homelessness, substance abuse treatment, and incarceration. He described selling sex to men in order to meet women as potential sexual partners and companions.

I like to look good….and to look good I do what I do…So I got to do what I got to do to buy what I want to buy, to make me look how I want to look... Well, you got a woman that looks at a man like “Damn, you can’t do a damn thing. You can’t take me out. You can’t do this or that.” You know? If I didn’t do those things [sexual exchange with men] then I would not be about to do those things for her so one benefits the other. You know what I’m saying? And that’s basically how I keep the thing rolling… I really dig this female. It’s not all about sex…I like to show my generosity and show that you know that I have, you know, I have a little bit of respect and I have some decency in myself to say ”Ok, let’s go out to a movie or I’ll treat

Gregory’s description of selling sex for money exemplifies a common sexual risk behavior described by a majority of the men and, in particular, the men with a history of homelessness, substance abuse treatment, and incarceration.

Unlike previous quantitative studies, I found no association between the proportion of drug partners in the respondents’ personal networks and their sale of sex for drugs or money (78, 98). Even with these null findings, the study limitations preclude me from dismissing this potential determinant of selling sex for drugs or money. This argument is especially important considering the association found between drug use and unprotected sex within the sexual partner dyads in the present study as well as strong evidence elsewhere that has shown associations between drug-using networks and sexual exchange (11, 78, 81, 98). To further support this argument, Frederick’s words exemplify his normalization of sexual risk behavior and his identification with the sexual exchange norms of his substance-using reference group.

I think I was locked up in penitentiary then, that’s when I first tried somethin’ crazy like that [having sex with a man], just to see if I would like it. ‘Cause guys was doin’ it and stuff, but I didn’t really like it, you know what I mean? So I stopped doing it. Then, when I got outside prison, and got on drugs and stuff, it made it a little easier. So I would tell myself it would be okay…. the drugs made it easier. I don’t know, seemed like when I was in prison and I tried havin’ that I couldn’t do that. I just couldn’t do that. Then when I got out and I got to runnin’ around, I met so many people that do this, you know what I mean? So many men, like men here. So many that do it and talk about it. “Man just get that money. Just don’t think about it. Go on about your business.” So that made it a little easier now.

Frederick’s remarks capture many of the men’s normalization of their sexual exchange and substance use, which may hinder them from reflecting on their risk behaviors and formulating risk reduction strategies. The desperation surrounding a majority of the men’s substance use also appeared normalized in their accounts of how substances often played a central role in organizing their daily lives. Such normalization and familiarity with these risk behaviors could lessen the men’s perceptions that these behaviors may be harmful to their health. Calvin provided insight into his

willingness to discuss how he sells sex to men with a confidante who has also struggled with serious substance addiction.

People that talk about eating out of garbage cans ‘cause they homeless, out there doing whatever they got to do, they understand. They understand how you can get into that type of [same-sex sexual exchange] relationship. Those are the people you choose, that you can talk to about it…’cause when you tell them about your having a homosexual relationship, they kind of know what you’re going through. They tell you their own story and that it was the quickest way, you know, to make money. And that’s what your entire story depends on, a quick way to make money.

The proportion of sexual partners in the respondents’ personal networks was not a predictor of selling sex for drugs or money. However, the personal network inventories were designed to elicit nomination of peers, in general, and not exclusively sexual partners. Therefore, underreporting of sexual partnerships is probable, which may have attenuated the relationship. As hypothesized, the likelihood of unprotected sex was significantly higher for sexual partner dyads that were categorized as primary sexual partnerships. This finding is consistent with other studies reporting that condom negotiation within closer sexual partnerships is often considered a violation of trust and may act as a disruption of intimacy (161). This result is also consistent with drug-related literature that describes increased challenges to engage in HIV protective behaviors among close intimates (116, 118, 119, 123). Many of the men from the qualitative parent study described the desire to be discreet about different sexual partners who were assisting them in meeting distinct needs. The following example from Gregory represents a subset of the men who reflected on the potential consequences of their sexual risk behaviors with multiple partners.

I don’t work, don’t have money. There are those necessities that I need. So basically, I have a male friend that you know, I engage in sex with him. And he, you know, gives me money in return, that way. That’s just how I keep myself in clothes, shoes, things of that nature. And I would hate for her to find out that I actually, you know, engage with other men. Because,

Gregory expressed a related sentimentabout his desire to appear sexually exclusive and present different sexual identities with his female and male sexual partners. This may, in turn, influence his respective partners’ condom use and other sexual risk reduction strategies.

To her, I’m straight. I’m all about a woman. To them, I’m all about a man (laughs). If I told one about the other, then I’d lose that one. Because they think all they got is me, even though they might have others. But when it comes to me, they think all they got is me, you know? And I keep it that way.

There were no associations between the four forms of social support and selling sex for drugs or money. In spite of these null findings, the proportion of peers as a source of social support within a personal network should not be rejected as a potential determinant of selling sex for drugs or money. Strong evidence showing the protective effect of social support on HIV risk behavior should be taken into account (72, 118). A majority of the men participating in the qualitative parent study remarked on the relationships they formed in prison that contrasted with their isolated lives after reentry in communities. Anthony, a 52-year- old, bisexual-identified, HIV-negative man with some college education who works part-time as a clerical worker, described his experiences in prison and the impact of the prison industrial complex on the lived experiences of African American men.

It is really a tool that society uses to castrate black men, to control black men. Keep ‘em where they are, because they are feared, feared where they want to be. They say they are feared because they are angry and whatnot, but they’re not. They are just made out to, made out to be angry, to be harmful… [In prison] I met some of the best people in my life, know what I’m saying? Some of the best people, and we both saw the best in each other.

Many of the men in the qualitative parent study reflected on the lack of social integration after prison release. Calvin is a 45- year-old, straight-identified, HIV-negative man with some college education who works as a brick mason and has a history of homelessness, substance abuse

treatment, and incarceration. He spoke of how the lack of social integration leads many men to return to substance use, sexual risk behavior with men, and criminal behavior.

I’m from the South, it’s [the culture] hush-hush, take to the grave with it. And thus, you continue to use [substances], continue to do this [same-sex sexual risk] behavior. Continue to rob banks ‘cause they ain’t had nobody to talk to. It’s crazy. There are people that rob and kill because won’t nobody sit there and talk to them. And I’ve been in the penitentiary and talked to people, and when they in the penitentiary, they so educational. They sit down and talk to you. You would never think that he was a murderer. But when they get out, the world shuns them so bad. It pushes them in a corner, don’t talk to ‘em, don’t communicate with ‘em, don’t give ‘em no opportunities. So they say “Let me go back right to what I know.”

Calvin’s remarks encapsulate the shared perception among the men that individuals with a history of incarceration occupy a lower social status and receive the least amount of social support. In addition, his words reflected his observations on intersecting stigma associated with race/ethnicity, sexual behavior, and substance use.

The dualistic influence of social support on risk behavior is evident across the three study